Postanal repair: which patients derive most benefit?

Forty-two patients (37 women, 5 men; mean age 61 years) with varying degrees of anal sphincter dysfunction were treated by postanal repair. Results were analysed in relation to age, sex, presenting complaint and the results of preoperative anorectal physiological tests. Complete continence was restored in 13 (31%), while acceptable but slightly impaired control was achieved in a further 17 (40%). Twelve patients (29%) remained or became totally incontinent. The likelihood of a successful outcome was greater in those presenting with complete incontinence (77% improved) than in those retaining control of solid stool (29% improved, 29% unchanged, 43% worse). Age and sex had no effect on results but pudendal neuropathy, identified in 74% overall, slightly reduced the chance of success. In nine postoperative patients studied, neither the anorectal angle nor anal canal length bore any relation to the results of surgery.     

Cystic medial necrosis in coarctation of the aorta: a potential factor contributing to adverse consequences observed after percutaneous balloon angioplasty of coarctation sites

Percutaneous transluminal angioplasty has been shown to be both feasible and efficacious for the treatment of aortic coarctation. Recent reports, however, have indicated that the development of aortic aneurysms at or near the coarctation segment may complicate attempts to treat this lesion by catheter-based intervention. Accordingly, we examined the light microscopic features of coarctation segments excised at surgery (n = 31) or obtained at autopsy (n = 2) in 33 patients with coarctation of the aorta. Cystic medial necrosis, defined as depletion and disarray of elastic tissue, was observed in each of the 33 specimens. In the majority of coarctation specimens (22 of 33 or 67%) the extent of cystic medial necrosis, graded semiquantitatively on a scale of 0 (normal aorta) to 3+, was severe (3+). The finding that cystic medial necrosis represents a consistent histologic feature of coarctation of the aorta provides a pathologic basis for the formation of aneurysms observed after balloon angioplasty of coarctation sites.     

Oral health of the methamphetamine abuser.

PURPOSE: The pharmacology of methamphetamine is reviewed, and the effects of methamphetamine use on oral health are described. SUMMARY: Methamphetamine is a highly addictive amphetamine analogue, initially synthesized in 1919. Illicit methamphetamine use leads to devastating effects on health, particularly the dentition. Illegal production of methamphetamine has skyrocketed in recent years, as have the number of users. The chief complaint of methamphetamine users is xerostomia. Without the protective effects of saliva, caries development in these patients is rampant. The typical pattern of decay involves the facial and cervical areas of both the maxillary and mandibular teeth, with eventual progression to frank coronal involvement. The acidic substances used to manufacture this drug have also been implicated as a cause of tooth decay and wear in users, as has bruxism as a result of drug-induced hyperactivity. When possible, these patients should be referred to a dentist to improve their oral health status and minimize the potential for adverse cardiovascular sequelae. Other preventive measures for methamphetamine users include stimulating saliva flow and increasing fluoride supplementation. Pharmacists should also counsel users to avoid carbohydrate-rich soft drinks in favor of water. Oral moisturizers may also be effective. CONCLUSION: Methamphetamine use causes xerostomia secondary to sympathetic central nervous system activation, rampant caries caused by high-sugar intake in the absence of protective saliva, and bruxism as a result of hyperactivity. Practitioners should know how to recognize the signs of and manage the oral health of patients with a history of methamphetamine use.     

The effect of light intensity on double bond conversion and flexural strength of a model, unfilled dental resin.

OBJECTIVE: Two visible light sources (tungsten-quartz-halogen and xenon-arc plasma) with vastly different intensities (200 and 1800 mW/cm(2)) but similar spectral outputs, were used to examine the effects of light intensity on conversion and flexural strength of a model dental resin formulation (75/25wt% bis-GMA/TEGDMA). METHODS: The exact same polymer samples were used to correlate double bond conversion (measured with near-IR spectroscopy) to flexural strength, both immediately after light exposure and after storage. RESULTS: In general, polymers which were irradiated with the high light intensity source exhibited greater double bond conversion. However, increasing the light intensity also increased the maximum temperature reached during polymerization. Therefore, the greater double bond conversion was caused by a combination of both photo and thermal effects. Regardless of the light intensity, a single linear relationship existed between conversion and final flexural strength (measured 4 days after cure) over the conversion range analyzed (50-80%). However, deviations from linearity were noted in several samples that were tested immediately after exposure. SIGNIFICANCE: These findings illustrate that light intensity does not affect the final flexural strength of a dental resin as long as the final conversions are similar.     

Impact of activated protein C resistance on general vascular surgical patients

Purpose: The prevalence of activated protein C resistance (APCR) and associated thrombotic morbidity among patients who undergo arterial reconstruction were investigated.Methods: Preoperative assays for functional APCR and factor V (Leiden) mutation were performed on 262 patients who underwent arterial reconstructions that consisted of cerebrovascular surgery (109), aortic or iliofemoral procedures (76), or infrainguinal bypass procedures (77). Patients were monitored for thrombotic complications during the postoperative period.Results: Depending on the stringency of the definition used, functional APCR was detected in 10.6% to 22.0% of patients tested. Factor V (Leiden) was found in 5.3% of patients. Thrombotic morbidity consisting of myocardial infarction, cerebrovascular event, or graft thrombosis occurred in 9.9% of patients, who were followed-up for a mean of 4.8 months. No significant overall correlations were found between APCR and thrombotic morbidity. Subgroup analysis revealed significant associations between functional APCR and total early postoperative thrombotic complications and early graft failure, and between factor V (Leiden) and early cerebrovascular events and late graft thrombosis (p < 0.03).Conclusions: Functional APCR is somewhat more prevalent among general vascular surgical patients than in the general population, but factor V (Leiden) is no more prevalent. APCR is not a prominent cause of thrombotic morbidity in contemporary vascular surgery. Nonetheless, it is a sufficiently important potential contributor to morbidity among some subgroups to warrant selective testing and directed therapy pending further study. (J Vasc Surg 1997;25:1054-60.)     

Effects of inotropes on human leucocyte numbers, neutrophil function and lymphocyte subtypes

We have investigated the effects of inotropes with different adrenergic receptor specificity on differential white cell count, lymphocyte subtypes and neutrophil function in healthy volunteers. Six healthy, male volunteers were enrolled into this randomized, placebo-controlled pilot study. Each volunteer was studied on four separate occasions during a 2-h infusion of various agents, and for 2 h after stopping the infusion. The agents investigated were adrenaline 0.1 microgram kg-1 min-1, dobutamine 5 micrograms kg-1 min-1, dopexamine 2 micrograms kg-1 min-1 and 5% glucose 0.5 ml kg-1 h-1. Venous blood was sampled at 0, 30, 120 and 240 min. Haemodynamic monitoring was continued throughout the study. Full blood count, white cell differential count and enumeration of lymphocyte subtypes were performed. Neutrophil function tests included chemoluminescence, and assessment of neutrophil chemotaxis, phagocytosis and adhesion. The Wilcoxon signed rank test was used to compare differences between placebo and active drugs at each time compared with baseline. There was a significant increase in white cell count, lymphocyte count and neutrophil count with adrenaline, and a small but significant decrease in these variables with dobutamine and dopexamine. These changes were also apparent for absolute CD3+, CD4+ and CD8+ lymphocyte counts. Neutrophil respiratory burst in response to f-methionyl-leucyl-phenylalanine increased significantly only with adrenaline at 30 min (P = 0.046). There were no other significant changes in tests of neutrophil function. Infusion of inotropes was associated with changes in white cell numbers, lymphocyte subtypes and neutrophil respiratory burst. In healthy volunteers, adrenaline had effects different from those of dobutamine and dopexamine. The clinical relevance of such effects requires further investigation in critically ill patients.      

Strengthened estimates of individual pain trends in children following bone marrow transplantation.

Pre-transplant conditioning regimens for bone marrow transplantation often cause oral mucositis and severe pain. We evaluated the agreement of self- and parent reports of daily oral mucositis pain in children between the ages of 6 and 16 years. Child patients were asked to report their pain on visual analog scales (VAS) daily for 20 days following their transplants. Daily VAS ratings were also obtained from one of the parents. The analysis sample consisted of ten children aged 7-9, nine children aged 10-12, eight children aged 13-16, and their parents. We modeled individual child and parent reports as quadratic functions of the number of days post transplant. Empirical Bayes/restricted maximum-likelihood estimates were obtained of individual coefficients, treated as random effects, and age group coefficients, treated as fixed effects. Parents exhibited higher average pain curves than their children in each of the three age groups. The middle age group reported the highest average pain. Average within-person error variances representing unreliability were 692.2, 461.9, and 303.9 for young, middle, and old children, respectively; for parents, the corresponding error variances were 375.1, 413.3, and 252.4. These results challenge the presumption that children tend to over-report pain but are consistent with the contention that younger children may be less reliable reporters than adolescents and adults.     

Azygoesophageal recess: normal CT appearance in children.

The azygoesophageal recess is the interface of the subcarinal portion of the mediastinum and the right lower lobe. The configuration of the recess on CT can be used as a sensitive indicator of abnormality in the mediastinum. In normal adults the recess is concave. A convex contour is a normal variant, particularly in young adults. The normal appearance of the azygoesophageal recess in children has not been studied. Accordingly, we reviewed chest CT examinations performed in 253 children ranging from 1 month to 20 years old. Forty patients were excluded from further analysis either because the recess could not be evaluated properly or because underlying disease caused the mediastinum to have an abnormal configuration. An age-related spectrum of normal configurations was observed in the remaining 213 patients. A convex or straight contour was found in 96% of children less than 3 years old. Scans of children 3-12 years old revealed a spectrum of configurations. The typical adult concave configuration was seen in 78% of adolescents more than 12 years old. Overall, in only 90 (42%) of 213 children in this study was a concave recess observed on CT. Our experience shows a convex azygoesophageal recess on CT should be considered the normal configuration in infants and young children. Recognition of this age-related variation is useful in the CT evaluation of the mediastinum in children.